Evidence for Welfare Practice Lecture 3.2 Evidence-based practice

What is evidence based practice? “… the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients … integrating individual clinical expertise with the best available external clinical evidence from systematic research” (Sackett et al 1996)

The emergence of evidence-based practice Began in the medical profession as a means of addressing the large number of clinical studies being carried out Addresses issues of rationing of health care Used to demonstrate professional accountability Increasingly a requirement of government initiatives

The emergence of evidence-based practice (cont’d) National Institute for Health and Care Excellence (NICE) to improve outcomes for people using the NHS and other public health and social care services by Producing evidence based guidance and advice for health, public health and social care practitioners. Developing quality standards and performance metrics for those providing and commissioning health, public health and social care services. Providing a range of informational services for commissioners, practitioners and managers across the spectrum of health and social care. The

The emergence of evidence-based practice (cont’d) Cochrane a global independent network of researchers, professionals, patients, carers and people interested in health Mission: to provide accessible, credible information to support informed decision- making for improving global health. Trusted evidence Informed decisions Better health

Evidence based practice is now applied to other disciplines, e. g Evidence based practice is now applied to other disciplines, e.g. nursing, education, pharmacy, probation work, social work, …

Social care EBP (UK) ‘The conscientious, explicit and judicious use of current best evidence in making decisions regarding the welfare of individuals, groups and communities’ (Sheldon, 2008 cited in Evans and Hardy, 2010, p. 45)

Why do we need evidence? Best practice Informed decisions Social care professionals need rigorous and systematic evaluations of intervention choices; in order to make informed decisions Informed decisions Enhance quality of service Enhance quality Avoid doing harm through interventions that are not effective or inappropriate Avoid harm For cost effectiveness Cost effectiveness Best practice

In EBP, there is a hierarchy of research in terms of their ability to reliably and directly inform practice. (McNeece and Thyer, 2004, pp10-11) Systematic reviews / meta-analyses Randomised controlled trials Quasi-experimental studies Case-control and cohort studies Pre-experimental group studies Survey Qualitative studies

Systematic reviews/meta-analyses It is a genuinely comprehensive interdisciplinary worldwide compilation of published and unpublished research which addresses a particular topic and which is carefully critiqued, and conclusions drawn. The very best systematic reviews incorporate a statistical methodology called meta-analysis, which enables one to compare findings across different studies which used different outcome measures in evaluating the effects of a particular treatment when used with clients experiencing a specific problem. (McNeece and Thyer 2004, p. 10)

Randomised controlled trials It involves the random assignment of clients to differing conditions, such as to an experimental treatment group, a standard treatment, to a placebo treatment group, or no-treatment group. (McNeece and Thyer 2004 pp.10-11)

An example of RCT

Randomised controlled trials (cont’d) Sometimes, a placebo group is used to combine with the treatment group, but clients must not know which group they are in  single-blind And if the researcher does not know either, it is termed as double blind to reduce bias.

Randomised controlled trials (cont’d) In RCT, a causal relationship between the intervention and outcome measured can be found.

Quasi-experimental research In this research design, it does not employ randomization techniques to assign clients to different groups, but make use of naturally occurring groups that receive different treatments (McNeece and Thyer, 2004, pp.10-11)

In quasi-experimental design, study participants are not randomly assigned.

Quasi-experimental research (Cont’d) Without randomisation, selection biases are likely to impact upon the findings. A causal relationship cannot be established.

Case control and cohort studies A cohort study involves the observation over a period of time of a group of people who have had a particular experience that equates with an intervention. E.g. children who have been in foster care and children not in foster care Subsets of the group may be compared or the group may be compared with a control group, to strengthen findings about relationship. E.g. those placed in foster care with siblings and those placed without siblings (Gray, Plath and Webb, 2009, p.35)

Pre-experimental research designs There is no control groups: simple efforts to evaluate outcomes such as looking at client functioning After receiving a service: a post-test only study Before and after service: a pre-post test design (McNeece and Thyer 2004)

Pre and Post Test

Pre-experimental research designs (Cont’d) Again, causal relationship cannot be found, because the changes measured may be due to other factors during the process of intervention, e.g. maturity effect.

Qualitative research Explore client’s subjective reactions to service, or to the examination of the processes of change Examine the complex and multi-dimensional nature of human experiences and seek factors that impact on these experiences Gather detailed information on experiences and meanings associated with interventions through e.g., observation, interviews, focus groups and analysis of existing transcript data such as case files

Other forms of evidence Evidence based on experiences of practitioners Evidence gathered from service users Evidence based on theories and knowledge derived from a variety of sources that has been found to be credible

Five steps for EBP

Step 1: Convert your practice problem into an answerable question Identify a question that is needed to deal with the problem of the service user(s) Beware not to set it too broad or too narrow

The question may relate to e.g. Step 1: Convert your practice problem into an answerable question (Cont’d) The question may relate to e.g. How best to reliably and validly assess (measure) a client problem (e.g. risk for abuse) How best to describe a client characteristic, attitude, or value How best to intervene to modify a client problem (Grinnell & Unrau, 2011, p. 168)

Step 1: Convert your practice problem Step 1: Convert your practice problem into an answerable question (Cont’d) Two examples: What are best practices to reduce violence behaviour in men in wife abuse? Is CBT an effective measure for children who have been sexually abused?

Step 2: Locate the best available evidence to answer that question Examples of sources of information The Cochrane Collaboration deals with issues related to the assessment & treatment of various health problems. The American Psychological Association's PsycINFO database is the comprehensive international bibliographic database of psychology, e.g. mental health, aging The Campbell Collaboration helps people make well-informed decisions by preparing, maintaining and disseminating systematic reviews in education, crime and justice, and social welfare.

Step 3: Critically appraise the evidence with your client You have to ask: Is there strong evidence that the treatment caused the improvements? How are the findings likely to generalize to the target population, problems, and setting that you work with? (Arean and Gum in Nash, Muford and Donoghue, p. 9)

Step 3: Critically appraise the evidence with your client (Cont’d) Ask: Is there strong evidence by checking The level in the hierarchy of evidence The research design The source of research evidence Whether the evidence can be generalised to you client group

Step 3: Critically appraise the evidence with your client (Cont’d) Check the usefulness of the evidence to your work, e.g. the similarity between the characteristics of the research sample and your client(s) in terms of Nature of problem Age Sex Ethnicity Education Income level (Arean and Gum in Nash, Munford and O’Donoghue, 2005, p. 9) Share your findings with your client

Step 4: Use your clinical judgement and your client’s preferences to apply that evidence to the present circumstance

Step 5: Evaluate effectiveness and efficiency in completing steps 1-4 Go through the steps and ask yourself What can be improved? Check with colleagues and literature

Evidence-based practice is The integration of the ‘best research evidence’ with clinical expertise and client values in making practice decisions An integration of research evidence, worker’s knowledge and practice wisdom + Service user’s values, preferences and involvement

At the end Haynes et al. (2002) emphasize that the professional expertise of the clinician is the ‘glue’ that combines and integrates all the elements of the EBP process.

The components of EBP Model (Haynes, Devereaux, and Guyatt, 2002) Clinical state and circumstances Clinical Expertise Client Preferences and actions Research Evidence

Mini-discussion What are some of the problems/challenges in applying EBP model in social work or social welfare?

Problems with this hierarchy of evidence? The levels of evidence focus predominantly on quantitative approaches. They ignore other perspectives such as qualitative, expert opinion, user perspective. It is questionable whether either quantitative or qualitative approaches alone are sufficient to address the diverse nature of problems in social care.

Other arguments against EBP in social care / social welfare Lack of available evidence Quantitative research is emphasised Time and resources are required A tool to cut cost?

Lack of available evidence Comparatively, there is less research in the social welfare field Probably more robust in the mental health sector RCT requires the intervention to be well defined, standardized and replicable. Exactly the same intervention must be administered in the same way to every participant in the experimental group. Difficult to follow in view of the individual skills and style of practitioner

Quantitative research is emphasised Social care/social welfare is concerned with people, who are complex in nature in terms of behaviours, thoughts, feelings and values. Qualitative research can offer information to help understand the importance and relevance of intervention in people’s lives.

Time and resources are required Doing research, particularly large scale research studies requires much resource in terms of time and money Which will induce demands on practitioners on top of their heavy workload

Evidence-based practice represents both an ideology and a method. (Bloom, Fischer and Orme, 2009)

Ideology Evidence-based practice represents the commitment to use all means possible to locate the best (most effective) evidence for any given problem at all points of planning and contacts with clients. (Bloom, Fischer and Orme, 2009)

Ideology (Cont’d) Building up of a critical culture in the social care/social welfare profession Practitioners should be more conscious about the necessity of delivering the best intervention and the importance of service research & evaluation Based on evidence support

Practitioners should Be committed to provide the best practice based on the best available evidence. Learn to be both A USER of evidence A PRODUCER of evidence

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